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Deafness in adults: A GP's questions answered

Otolaryngologist Professor Anthony Wright answers GP Dr Graham Archard’s questions on red flags for deafness, grommets for adults and iPods

Otolaryngologist Professor Anthony Wright answers GP Dr Graham Archard's questions on red flags for deafness, grommets for adults and iPods

1. Are there some simple self-help measures for those with early hearing loss before they move on to a hearing aid?

Hearing involves not only the ears but also the eyes for recognising facial expression and lip movements in the speaker, and the brain for extracting the individual speech pattern from the background ‘noise' and then putting into context what is to be expected given the previous information. That is why the game of ‘Chinese whispers' so often gives the wrong message. So lip-reading classes and closely observing speakers is helpful but there is good evidence that early use of a hearing aid is more beneficial than waiting until later.

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2. Are digital hearing aids so much better than analogue, and are private ones any better than NHS?

For many (but not all) applications, digital aids are better than the older analogue aids. However, the reality is that the NHS now only provides digital aids. There are some aspects of private aid provision that are better than NHS provision.

For example, the NHS does not provide ‘in the ear' aids and many people would prefer this option. The limiting factor in all aid provision is how good the ear is and what information it can transfer to the brain (see point 1 above).

The range of NHS aids is somewhat restricted but overall extremely good. The quality of the service does, it seems, vary considerably from place to place.

3. What assessments should a GP ideally undertake before sending a deaf person to audiological assessment or ENT?

Look in the ear. Is the eardrum normal? Do a whisper test to get a general assessment of the hearing in each ear. If you have a tuning fork (512Hz C1), strike it and apply it to the forehead of the patient (Weber test) and ask where they hear it. If there is one-sided hearing loss and they hear it in the deaf ear, the problem is conductive – that is, in the middle ear. If they hear it in the better ear, the problem is sensorineural in the deaf ear.

If the hearing is poor in both ears and the tuning fork tests are ‘central', you need a proper audiogram. If this is available with good ‘masked' bone conduction, referral to ENT is appropriate for a conductive loss and to audiological medicine for a sensorineural loss.

4. What are the deafness red flags?

A one-sided sensorineural loss, or one-sided hearing change with a normal eardrum and a Weber test (see above) lateralising to the good ear, or unilateral tinnitus, are all strong indicators for referral to exclude an acoustic neuroma. There are lots of cases where the patient says they cannot hear in one ear and have a normal audiogram and yet have a large acoustic neuroma.

Are grommets used in adults and are they effective treatment for middle ear disease?

Ventilation tubes (grommets) can be very helpful in the rare cases of adults with glue ear, that is persistent secretory otitis media. This small group have persistent fluid in the middle ears from causes such as Wegener's granulomatosis, continuing allergies, previous local radiotherapy and so on. They are sometimes also needed for those who have continuing Eustachian tube insufficiency, as in cleft palates.

As might be expected, grommets are not cures but treatments. They are useful in maintaining the hearing but need continuing care from an ENT department.

People who have pressure problems on flights may also need ventilation tubes if the problem is severe.

5. What is the role of surgery in treating adult deafness?

Although there is the common perception that adult deafness is because of damage to the inner ear, the reality is that the more serious hearing losses in the middle and older age groups are secondary to middle ear damage. The sensorineural losses are usually related to the higher frequencies and relate to hearing speech in background noise. There is no surgery for these losses.

The conductive losses involve the middle ear and accumulate through life with middle ear damage. Many destructive conditions, such as cholesteatoma, might be prevented by good ENT care in the early days, but this is not easy and not resourced. Conditions such as otosclerosis develop insidiously, and respond to surgery despite a small risk of profound hearing loss.

6. What is the real truth about long-term hearing damage and MP3 players?

Only time will tell the real risk of MP3 damage but the smart money is on a generation who develop age-related hearing loss some years earlier than they would have had they not used any form of ear-level, high-volume, continuous sound from MP3 players. It is the continuous nature of the high-level sound that does not allow the sensory hair cells of the inner ear to rest between each new song that is probably the reason for the damage.

The hair cells form part of an active mechanical amplifier system in the inner ear – that gives rise to the cochlear echoes or otoacoustic emissions OAEs – and which needs energy to function. Continuous noise depletes the system and causes damage.

7. What is on the horizon regarding the management of adult deafness?

I have written here about the conductive deafnesses that cause most of the profound hearing losses in adults. The sensorineural losses are usually caused by changes in the inner ear, with loss of the auditory sensory cells. Some years ago researchers at the UCL Ear Institute found that the balance cells of the mammalian inner ear could regenerate after damage. The search is now on for factors that can lead to regeneration of the auditory sensory cells. Stem-cell replacement is another option and it is probably only a matter of time before a solution emerges.

8. What design changes can be made to surgeries to benefit the hard-of-hearing, and are grants available for these changes?

There are a number of improvements you can make to your premises to help deaf or partially deaf patients, including:

• installing loop systems

• having sound-absorbing wall coverings to reduce reverberation

• having buzzer pager systems for the severely deaf to know when it is their turn

• installing a visual display system to let deaf patients know that it is their turn

• employing someone who can converse in British sign language.

The Disability Discrimination Act applies to deaf people as well as those in wheelchairs. Because it is a statutory duty to provide for disabled people, grants seem to be more difficult to obtain nowadays but costs are not high and an application to local authorities or the PCT could be successful.

Profession Anthony Wright is a professor of otolaryngology and clinical tutor at the UCL Ear Institute

Competing interests None declared

Take home points What I will do now What I will do now

Dr Archard considers the responses to his questions

• Lip-reading classes are a great idea.
• I always thought it was best to wait as long as possible before suggesting hearing aids so this is interesting. I think the trick is to balance providing one too early, leading to intolerance, and too late, therefore losing some benefit.
• It seems that in general there is little to be gained by spending shedloads of money on private provision.
• We're usually unable to refer for MRI scan to exclude neuroma. It would seem that we should be able to refer directly and not to outpatients initially as most MRI scans for acoustic neuroma are negative.
• It appears it's still worthwhile referring adults with chronic suppurative otitis media to the ENT department.
• It is interesting that it is the continuous noise level from the earphones of MP3 players that is most important and this does give some room for manoeuvre when making ‘deals' with teenagers.

Dr Graham Archard is a GP in Dorset

Ear examination

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